Medical Coding Documentation Best Practices

If there’s one thing medical coding is known for, it’s documents

Fortunately, thanks to modern technology, most of the documents involved in medical coding are digitally based.

But it can still be difficult to keep track of documents, no matter whether they’re stored digitally or physically.

Here are some best practices to keep in mind for your medical coding documents moving forward:

Keep Documents Secure

Protecting patient information is paramount in healthcare. This is why it’s so important to ensure documents are secure, from the security protocols in place for any cloud-based or digital storage solution your organization is using to the presence of cell phones in rooms with sensitive information. If there are any areas of your documentation storage and organization that are compromised, fix it now while you can (or bring it to the attention of your supervisor).

Follow Company Guidelines

It can be tempting to skip a few corners in the busy world of medical coding, but the industry thrives on coders being attentive to details and following guidelines a company has in place. Not only does this protect your career and job security, not following company guidelines with coding and patient information could lead to legal issues. At the end of the day, follow guidelines your company has in place for coding and don’t let any documents out of your sight.

Never Share Sensitive Info

Building off of the first two points, don’t even share sensitive information with a spouse, friend or trusted family member. HIPAA is in place for a reason and both the government and medical institutions take it seriously. Even if you’re off the clock, be careful what you divulge about your company, patients and other information.

Be Honest

You not only need to be transparent and honest with our own company when it comes to documentation, you need to with third parties as well. Don’t lie or exaggerate with codes that you’re submitting to insurance providers and don’t compromise your values just because a doctor asks you to. Be open and be honest, especially with documents.

Perform Regular Audits

If you’re still not sure what to improve with your medical coding documentation, it might be time for an audit. Hopefully, your healthcare organization performs these regularly anyway, but even if they don’t, you can perform an audit on your own documentation practices and see if there’s any room for improvement. Not only will this help you stand out at your company, you’ll potentially improve co-worker and company-wide performance.

If you’d like to learn more best practices and connect with fellow medical coding peers, join our Facebook group today!